KEY ROLE OF PROGRESSIVE NOT AGGRESSIVE NUTRITION

Interview with Professor Michael Hiesmayr, Professor of Cardiothoracic Anaesthesia and Intensive Care at the General University Hospital of Vienna by Meg Blogg Marquardt, Nestlé Health Science

From ESICM Paris 23^rd October 2018

MB: Good morning Professor Hiesmayr. We’re here at the ESICM Congress in Paris with Professor Michael Hiesmayr, Professor of Cardiothoracic Anaesthesia and Intensive Care at the General University Hospital of Vienna. So we’ve had a couple of interesting days at the meeting here and there’s been a lot of nutrition, actually, I think at this intensive care meeting. Have you got some comments on what you’ve observed on the nutrition dialogue that you’ve been part of for so much of the discussion here?

MH: I’ve seen quite often major issues that I have identified that many of the speakers referred to the new published ESPEN guidelines on nutrition in intensive care and that quite apparently different positions have been narrowed and that we are now looking more to improve in small steps what we are doing. It’s, I think, a careful guideline and that covers many aspects.

MB: So careful  conservative, it’s not too intimidating?

MH: No, you know, it’s a very long text but the essentials are quite simple at the end. It’s progressive nutrition, not aggressive nutrition, having always your target in mind and trying to reach your target in an appropriate period of time of, let’s say, four or five days, and carefully watching the patient and their reaction to what you are doing. And I think the big fight between parenteral and enteral, that is also reduced because parenteral is treated similarly to enteral with the build up.

MB: So it’s a guideline where you think you’ll get common adoption across the different units and less resistance to it?

MH: Yeah, I think that the people that were involved in creating the guideline, and I was part of that project, I think it was a very diverse faculty that collaborated and it certainly helps that the evidence was reviewed by an external group from Canada, so it’s not only from the inside.

MB: Good. It gives you a lot of confidence by the sound of it, yes. Well, thank you, we’ll look forward to see how they’re adopted in the next coming years. In a couple of your talks, you referred to Nutrition Day, and you showed some very interesting information that seemed to evolve from that but can you tell us more about this Nutrition Day?

MH: So Nutrition Day is a once-yearly benchmarking and research project. I think…for the individual participating units, I think that benchmarking is at the centre of the project because if a centre contributes with the data collected on one to three days to have a sufficient number of ICU patients included they get, immediately after finishing the data input, a report completely comparing the activity in the unit and comparing the patients with the overall community of the patients that have been recruited so far. It’s more than 15,000 patients until now. So we can really refer to the actual practice. We do not issue recommendations how it should it be but how one unit compares to the overall community as a reference. And I think this is giving back autonomy of checking the process to the individual units. And, of course, we are very happy to utilise this data also to generate more systematic analysis of current practice and to give it back to the community.

MB: Is this Europe-wide, Professor?

MH: This is a world-wide project that is run in local languages. That is very important. The questionnaires are not only in English but in…for the overall Nutrition Day it is in 31 languages. And the data input is also adapted to the languages. So you have English, Italian, German, Spanish but also Japanese, Korean, Chinese, Hebrew, so it’s really very diverse and it allows really to facilitate the data acquisition because then any person in the team can collect the data, the data entry is also very intuitive. And, finally, I really would say we tried to reduce the barriers for participation with this approach to…and the data comes from, let’s say for ICU it’s in…from, I would say, roughly 40 countries.

MB: Okay, it’s only ICU, it’s international and it’s once a year?

MH: It’s once a year. The next time will be on 15 November 2018.

MB: Okay.

MH: And for units that are not able to participate exactly on that date, they are able with the office also to arrange for a different date. We are quite flexible in…it’s a network of, I would say, intensivists dedicated to transparency.

MB: And what is your role in Nutrition Day?

MH: I’m the head of the project and the technical team is also in Vienna and it originated within the community of ESPEN intensivists. It is endorsed by the European Society of Intensive Care Medicine as well. And then…so with my team, I developed the idea for intensive care, my major partner in developing it was Pierre Singer. And we are updating it in regular intervals. So it’s not only available for intensive care, there are also versions of the project for normal wards and for nursing homes.

MB: Okay. And the primary objective is of benchmarking?

MH: The primary objective is benchmarking for the participating units.

MB: Okay.

MH: But there is also…there are two other important issues. It’s creating awareness and generating, for all the participators, a common vocabulary so they collect similarly the data, they ask the same questions and so they can enter in dialogue with other units and share the data with them. So I think it’s really creating a community that understands each other in this regard.

MB: And they can access the data on a website?

MH: It’s a website, it’s free, you have to register, only you need to have an email address. This is controlled data, anonymously collected for the patients and for the units. We do not identify them. So it’s…the whole responsibility remains with the unit what they do with the data. And I think this is very important because benchmarking where you could identify individual units is not helpful because the unit has to understand the data not just some external authority. And it’s highly protected and it’s protected also by structure. We included all features so that there can be no data leak that can allow identification of any unit.

MB: That’s a three-day data collection of nutrition?

MH: Yes, it’s… for the normal wards it’s only one day.

MB: Okay.

MH: But based on the size of the ICU, to get a good overview and that the sample is stable, we propose to start on the first week on a Thursday, the next week you add only the new patients that came in in the past six days and so it’s on a Wednesday the second collection and then it’s on the next Tuesday, so six days later, so you get a spectrum from the different days. And you have a well-mixed range of short stayers and especially enough long stayers also.

MB: And are there any constraints to being part of this survey?

MH: There are no constraints at all. It’s sufficient to register properly on the website. And I think the important thing is if you collect your data about the status of the patient, and the nutrition care that is associated and the part of the history of the patient as it is present in your charts, please do not forget to collect also the outcomes 60 days later because all these parameters that identify risk or treatment, we would like to relate them to outcome.

ADDITIONAL NARRATIVE

MB: I’ve got one final question. What…is there an example you can take from Nutrition Day that’s changed practice in your institution from your learning, from gathering this data?

MH: In this data we found really that in many units apparently the ordering of the nutrition is a once daily order but energy consumption is something that is more related like a rate. And so they order often one bag, so it’s one litre or one-and-a-half litres and it’s not completely adapted to the patient’s weight and size. So I really encourage units to rather take a rate for the nutrition instead of ordering one unit per day.

MB: Well, thank you, it’s been very interesting. I’m looking forward to seeing how the ESPEN guidelines will impact the change in practice over time. And good luck with the next Nutrition Day. Thank you

MH: Thank you very much, Meg for this interview.

END.